Study & analysis Optimal BP for High-Risk Patients: Subanalysis of the CASE-J Trial
The recently published CASE-J trial was the first large-scale Japanese outcome study comparing candesartan- and amlodipine-based therapies. (1) Among 4,703 high-risk hypertensive patients, candesartan- and amlodipine-based regimens produced no statistical differences in terms of the incidence of cardiovascular (CV) events. However, across an average of 3.2 years of follow-up, candesartan was associated with a 36% relative risk reduction (p = 0.033) in new onset diabetes compared to amlodipine-based therapy. Candesartan also was better at reducing total mortality in obese Japanese patients. (1)
Given that CV event rates and the severity of obesity in Asian countries differ from those in Western countries, it’s important to specifically evaluate the efficacy of drugs that are widely used all over the world. The CASE-J investigators also conducted a subanalysis evaluating the relationship between the incidence of CV events and achieved blood pressures in patients with type 2 diabetes mellitus (DM), chronic kidney disease (CKD), or left ventricular hypertrophy (LVH). The objective was to determine the optimal BP levels for the prevention of cardiovascular events in high-risk hypertensive patients. These data were presented at Hypertension 2008 by Toshio Ogihara, Osaka University, Graduate School of Medicine (Japan).
Regardless of assigned treatment, event rates were markedly lower once BP was lower than 140/85 mm Hg, whether or not they had DM, CKD, or LVH. As expected, the incidence of CV events was higher in those patients with any of the comorbid conditions evaluated. The blood pressure threshold for increased events was different depending on whether patients did or did not have the specific comorbidities.
Specifically, patients with type 2 DM, CKD, or LVH showed increased risks of CV events even when BP was 130/80 mm Hg or greater, whereas the relative risks in patients without those complications increased at BP levels >/= 140/85 mm Hg. (For an example of the crude CV event rates by achieved BP, see Figure 1, Figure 2 and Figure 3 for the data on patients with and without DM.)
Thus, the evidence confirms that to prevent cardiovascular events in hypertensive patients with type 2 DM, CKD, or LVH, it’s crucial to target BP to less than 130/80 mm Hg.
References:
Ogihara T, Nakao K, Fukui T, et al. Effects of candesartan compared with amlodipine in hypertensive patients with high cardiovascular risks: candesartan antihypertensive survival evaluation in Japan trial. Hypertension 2008;51:393-8.
